Oakland Southfield Physicians


The Patient Centered Medical Home (PCMH)

The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive care to adults, youth and children. The PCMH will broaden access to primary care, while enhancing care coordination with the broader care community. Primary care physicians practicing in the highest level medical home will:

  • Take personal responsibility and accountability for the ongoing care of patients;
  • Be accessible to patients on short notice, for expanded hours, and open scheduling;
  • Be able to conduct consultations through email and telephone;
  • Utilize the latest health information technology and evidence-based medical approaches, as well as maintain updated electronic personal health records;
  • Conduct regular check-ups with patients to identify looming health crises, and initiate treatment/prevention measures before costly, last-minute emergency procedures are required;
  • Advise patients on preventive care based on environmental and genetic risk factors they face;
  • Help patients make healthy lifestyle decisions; and
  • Coordinate care, when needed, making sure procedures are relevant, necessary, and performed efficiently.

To realize this vision, primary care physicians cannot work alone.  The evolution of the PCMH model has recently expanded to include specialists.  This model is referred to as the PCMH-Neighborhood (PCMH-N).  

The PCMH-N is a community of caregivers that measure performance, set goals, track progress, and coordinate services across the care continuum for its patient population. The neighborhood accepts responsibility for delivering effective and efficient patient care across care settings.  To embody this commitment, we follow these principles of patient-centered care:

  • The option to develop an ongoing relationship with a personal physician;
  • Physician-directed medical practice;
  • Whole person orientation;
  • Coordinated care across the health system;
  • Ongoing, voluntary pursuit of quality and safety;
  • Enhanced access to care; and payment recognizing the value added.

Click below to watch a short video (Español vídeo) which explains the PCMH concept.

Call ANI at 248.357.4048, or fill out an inquiry online or email us for assistance.

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